By Gregory Collins, MD
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During my 40 years in medicine, America has endured approximately five drug epidemics, from LSD in the 1960s to crack cocaine in the 1980s. None of the previous epidemics compares to today’s horrendous plague of prescription drug abuse and heroin addiction.
This epidemic is killing far more people than its predecessors. Fueled by powerful opioid drugs and cheap heroin, the rate of drug overdose deaths has tripled since 1990. Drug overdoses have become the leading cause of injury death in the United States, killing 43,982 people in 2013, according to the Centers for Disease Control and Prevention. Pharmaceuticals, predominantly prescription opioid analgesics, caused most of those deaths.
Large increases in overdose deaths
Opioid addiction and its tragic consequences touch every facet of every community, from the central city to suburbs, rural towns and small villages. In Cuyahoga County, home of Cleveland Clinic, 195 people died from heroin overdoses in 2013, according to the county medical examiner. That is a 21 percent increase from the previous year and nearly five times the number of heroin overdose deaths that occurred in Cuyahoga County in 2007. Other major metropolitan areas have seen similar rises.
This is a full-blown public health crisis. The time has come for the medical community to acknowledge that it should be part of the solution.
Physicians who prescribe opioids are increasingly aware of the risks and problems of using these powerful drugs. We have come through a period in which aggressive treatment of pain was the norm. Now, we have a much more cautious mindset. Physicians and patients alike are coming to the realization that minor pain should be treated first with nonsteroidal anti-inflammatory drugs or similar nonopioid medications.
(In Cleveland Clinic’s Department of Pain Management, the role of opioids in treating chronic pain is very small and limited to a narrow subset of patients, mostly those with cancer. Also, any plan to start a patient on opioids must include a plan to monitor their effect using specific outcome measures and to stop their use if defined treatment goals aren’t met.)
People addicted to painkillers have helped drive demand for heroin. Addicts turn to heroin because it is cheaper than prescription drugs and in many cases is easier to obtain. Heroin also has lost its reputation as a drug to be feared. It has become fashionable and seems less risky. First-time heroin users often believe they can smoke it rather than resorting to a needle. When they become addicted, smoking quickly gives way to injection, with a heightened risk of overdose and death.
In my position as an addiction psychiatrist, I often ask our young opiate patients, whose average age is 22, if they have ever experienced cardiac or respiratory arrest and had to be resuscitated. Most say yes. They also say many of their friends are already dead from overdoses.
Responding to the crisis
These dreadful things don’t have to happen. But to curb an epidemic that grows like cancer, we must answer the call to action. Cleveland Clinic has decisively stepped up to address this public health crisis.
In 2012, Toby Cosgrove, MD, CEO and President of Cleveland Clinic, hosted our region’s first Drug Enforcement Summit, in collaboration with Steven M. Dettelbach, U.S. Attorney for the Northern District of Ohio. The second summit, in November 2013, drew more than 1,000 people and produced a community action plan that deals with prevention and education, healthcare policy, law enforcement and treatment. This broad-based community initiative is drawing national attention as a model for responding to the problem of rampant drug abuse.
One outgrowth of this initiative is a growing understanding that we cannot arrest or treat our way out of the problem. But we can follow national recommendations. They include increasing public education about abuse, addiction and overdose deaths. We need a strong educational thrust in middle schools, high schools, colleges and medical schools. Laws and regulations governing the prescribing and dispensing of opioids should be tightened. Drop boxes should be made available at police stations for the secure disposal of unneeded or excess prescription pain medications, to get them out of circulation. We need more addiction treatment availability and capacity, from inpatient detoxification facilities to outpatient management with medication and counseling.
Cleveland Clinic provides stepwise treatment that matches individual patient needs, including detox therapy for outpatients, counseling, toxicology testing and medication assistance as needed, along with traditional 12-step approaches.
Buprenorphine and naloxone
Medication-assisted treatment with buprenorphine has revolutionized anti-addiction therapy, producing impressive outcomes. Our addiction research at Cleveland Clinic is finding that about three-fourths of heavily dependent opioid users respond well on buprenorphine. Our comprehensive treatment approach, including buprenorphine use, often helps patients break their addiction and gain a new lease on life.
We also need laws such as one passed recently in Ohio that improve the availability of naloxone for emergency use by addicts, family members and first responders. Naloxone reverses overdoses instantly, saving lives that otherwise would be lost. Public education is needed so bystanders know that an overdose is a critical emergency. In several places, Good Samaritan laws are being enacted to protect bystanders who report drug overdoses.
Most states now have prescription-monitoring programs that have become very effective at identifying drug abusers and doctor-shoppers. Physicians who treat pain patients with opioids should be trained to routinely use these monitoring programs as part of their practice.
The abuse of controlled medications is a national emergency. The casualties from this epidemic will soon exceed all the losses from the Vietnam War, with no signs of abating.
Our summit meetings in Northeast Ohio have shown that the medical community is ready to work with lawmakers, law enforcement personnel and the courts to combat the misuse of prescription drugs and the spread of heroin.
Here in Ohio we are creating a national model for responding to this epidemic. If we use our collective brainpower, we can reduce the spread of addiction and save lives. We can prevent more parents from getting a call in the night that their child was found dead with a needle in his or her arm.
Dr. Collins is Section Head of Cleveland Clinic’s Alcohol and Drug Recovery Center, which he founded in 1980. He also chairs the Health Policy Committee of U.S. Attorney for the Northern District of Ohio Steven M. Dettelbach’s Heroin and Opioid Task Force.